Peer Review eNews

​CIMRO was first accredited by URAC from 2001 to 2009 as a Health Utilization Management organization, and then as an Independent Review Organization since 2009. The rigor of the accreditation process confirms our processes meet industry best practices.

URAC provides a framework for creating organizational structure and management, and accreditation demonstrates commitment to quality and accountability.

CIMRO recently received full accreditation pursuant to Independent Review Organization: External Review, Version 5.0 for the period September 1, 2018, to September 1, 2021. This accreditation allows CIMRO to perform reviews for state departments of insurance that are representing members who have had benefits denied by their health carriers.

Accreditation is a voluntary and time-consuming undertaking by the organization. Preparation for the accreditation begins several months in advance. A lengthy desktop application requires demonstration on how each standard is met. URAC reviews the application prior to the site visit. Auditors spent one day at CIMRO’s office, reviewing our documentation and compliance with policies and procedures. They also interviewed a sampling of PRs and staff to gauge understanding and compliance.

Difficult as it can be, the process ensures CIMRO is current with health-care regulations and state regulatory requirements. It also provides standardization and consistency for processes across the organization. It further ensures privacy and confidentiality of protected health information, supports continuous quality improvement efforts, and provides opportunities for ongoing education.

As an example, standards are set for organizations to guide peer reviewer selection by assuring:

The organization establishes and implements a reviewer credentialing program.

The credentialing program shall address Primary Source Verification (PSV) of the requisite licensure or certification required for clinical practice. If the MD, DO or DPM is board certified, then PSV of the reviewer’s board certification is required Also mandated is verification of history of sanctions and/or disciplinary actions, and information regarding length of time providing direct patient care and when the relevant direct patient care last occurred.

The organization must specify that all reviewers have a non-restricted licensure or certification in a state of the United States.

The reviewer must have at least five years full-time equivalent experience providing direct patient care.

The reviewer must have a scope of licensure or certification and professional experience that typically manages the medical condition, procedure, treatment, or issue under review.

The organization must define and verify reviewer conflict of interest. The reviewer must attest that they do not have conflicts of interest, according to the organization’s definition.

CIMRO is proud of its 17 years of URAC accreditation. CIMRO has received a 100 percent pass rate during the previous two re-accreditation cycles. Not only that, but URAC representatives consistently remark that CIMRO’s performance is exceptional, with its organization and attention to detail.